Navigating the Complexities of Pressure Injuries (Ulcers)

This monthly blog will discuss all the components of quality clinical documentation with a comprehensive approach to cover all areas of the healthcare industry.

By Chinedum Mogbo, MBBS, RHIA, CDIP, CCDS, CCS


The National Pressure Ulcer Advisory Panel (NPUAP) redefined the definition of pressure injuries during the NPUAP 2016 Staging Consensus Conference that was held April 8 – 9, 2016 in Rosemont, IL.  The terminology change from “pressure ulcer” to a more precise “pressure injury” is not just a change in verbiage, but represents a more specific definition and classification of skin pathology.

Even though the skin is the largest organ in the body, it is often not given the required attention with regards to disease processes that affect the skin.

According to the NPUAP announcement:

“A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.”

Coding and clinical documentation improvement (CDI) professionals have a common goal to ensure that if a pressure injury is documented, that its present on admission (POA) status is validated. This is especially true for pressure injuries that are stages 3 and 4. If these are not POA, they are considered hospital-acquired conditions (HACs). HACs bring both financial and quality of care consequences that may be reported to various regulatory entities.

Some pressure injuries that occur in a healthcare setting are unavoidable and despite definitions published by the Centers for Medicare and Medicaid Services (CMS) and NPUAP, there are no universally accepted criteria for determining whether a pressure injury was avoidable or unavoidable.

By specifying the staging within the clinical documentation and using the definitions by the NPUAP, there is a renewed focus on deep tissue pressure injury (DTPI) which can be POA and exposed during the hospitalization to reveal an Unstageable, Stage 3, or Stage 4 pressure injury. The POA status of the revealed ulcer can be argued as being POA, especially if the DTPI was recorded at the time of admission.

To refresh our memories, the ICD-10-CM Official Guidelines for Coding and Reporting defines Present on Admission (POA) on page 110 as:

“… Present at the time the order for inpatient admission occurs– conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.”

The FY 2017 ICD-10-CM Official Guidelines for Coding and Reporting states on page 51:

“If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.”

The updated guideline has brought some confusion as coding and CDI professionals now have to assign a POA status to a pressure injury that was clearly POA and “N” for the progressed stage. This guideline poses a challenge especially when the progression of an ulcer is unavoidable. This may result in a number of healthcare centers and physicians experiencing a decline in their performance and quality of care profiles and, consequently, getting penalized financially.

The new guideline poses a serious challenge with regards to querying physicians for POA statues of pressure injuries that evolved and can be arguably defended as being unavoidable, and thus a POA dilemma. For instance, if a physician documents a stage 2 and 3 pressure injury of the same site as being POA, based on the guideline of clinical validity, we have no choice but the code the two stages as POA.


Black, Joyce M. et al. “Pressure Ulcers: Avoidable or Unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference.” Ostomy Wound Management 57(2), 2011: 24-37.

Centers for Medicare and Medicaid Services. ICD-10-CM Official Guidelines for Coding and Reporting 2017.

Edsberg, Laura E. et al. (2014). “Unavoidable Pressure Injury.” Journal of Wound, Ostomy, and Continence Nursing 41(4), 2014: 313-334.

National Database of Nursing Quality Indicators. “After Data Collection.” Pressure Injury Survey Guide.

National Pressure Ulcer Advisory Panel. “NPUAP Pressure Injury Stages.”

Pittman, Joyce et al. “Unavoidable Pressure Ulcers: Development and Testing of the Indiana University Health Pressure Ulcer Prevention Inventory.” Journal of Would, Ostomy and Continence Nursing 43(1), 2016: 32-38.


Chinedum Mogbo is an AHIMA-approved ICD-10-CM/PCS trainer and is the corporate director for CDS training at a California-based health system.

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